CASE STUDY
A 51-YEAR-OLD WOMAN WITH END-STAGE COPD
—
Gerard J. Criner, MD
BACKGROUND
A 51-year-old African-American female patient
presented to the health center’s emergency department with severe dyspnea on exertion and progressive edema of the lower extremities. She reported
that her breathlessness and coughing episodes had
become particularly severe in the preceding 3 weeks
and was now at the point where she could not stand
or walk for more than 1 minute to 2 minutes without becoming fatigued.
HISTORY
She is a 40 pack-year smoker (ie, about 1 and 1/2
packs per day since her mid-20s) and currently still
smokes cigarettes. She is not taking any medications
and has no family history of asthma, allergy, or cardiovascular disease. She claims to have never been
treated by a doctor.
PHYSICAL EXAMINATION
Woman with moderately above normal body mass
index who is in obvious respiratory distress. Decreased
breath sounds and obvious cyanotic skin. 2+ lower
extremity edema to thigh. She had neck vein distention and a positive hepatojugular reflex.
S420
Respiratory rate:
Heart rate:
SaO2:
30 per minute
115 bpm
78%
Arterial blood gases:
PaO2:
PaCO2:
pH:
HCT:
Prealbumin:
41 mm Hg
66 mm Hg
7.28
48%
low normal
Repeat arterial blood gases:
113 mm Hg
PaO2:
92 mm Hg
PaCO2:
pH:
7.28
FURTHER EVALUATIONS
Echocardiogram revealed severe right ventricular
hypokinesis and a right ventricular systolic pressure of
55 mm Hg. Catheterization of the right side of the
heart showed a pressure of 70/30 (48) mm Hg and a
cardiac output of 4 L/minutes with no O2 step-up.
The forced expiratory volume in 1 second (FEV1) was
0.38 L (16%); the residual volume was 5.97 L
(373%); and the ratio of residual volume to total lung
capacity was 84%. Diffusion capacity was 7.8 mL/mm
Hg/min (41%). The ventilation/perfusion matched
abnormality in both lower lobes, and there was 7%
quantitative perfusion to the bases, demonstrating
oligemia to the lower lobes.
MANAGEMENT
The patient was deemed to be in acute respiratory
distress and to have severe smoking-related chronic
Vol. 3 (5B)
■
May 2003
CASE STUDY
obstructive pulmonary disease (COPD). She was gas
smoking-cessation program, earlier introduction of
trapped and hyperinflated without significant diffuse
medical therapy might have delayed and possibly
emphysema. After immediate admission to the intenaverted the need for transplantation in this patient.
sive care unit, she was started on bronchodilators, sysThe complete absence of medical evaluation, counseltemic steroids, inhaled steroids, antibiotics, and
ing, or therapy for this lifelong smoker is, unfortunoninvasive positive pressure ventilation (NPPV).
nately, common. In this worst-case scenario,
After 3 weeks of inpatient hospitalization she was disinterventions such as steroids, oxygen, and NPPV
charged to her home with chronic nocturnal NPPV
allowed the patient to be more comfortable while waitand supplemental oxygen. She was also referred withing for the appropriate lung procedure. Reviewing this
in the health system for immediate outpatient rehabilcase of a patient with end-stage COPD should remind
itation, smoking cessation, and weight monitoring. A
clinicians of the reasons for instituting early and
flutter valve device was provided for management of
aggressive smoking-cessation efforts and the need to
coughing exacerbations.
develop newer medical therapies and surgical techDue to the severity of lung function deterioration
niques that may prevent or at least delay the need for
(eg, FEV1 well below 25%) and the inability of medthe most radical COPD solution. The demand for
ical therapy to relieve symptoms, this patient was listsuch symptom-based interim therapies will increase in
ed for lung transplantation. She had no significant
coming years as United States health systems are
change in her condition in 3 years and underwent
forced to deal with that large population of patients
double-lung transplantation. Performance as measured
with COPD who have already progressed to the more
by lung function (Figure) and by physical function
advanced stages of the disease.
and her quality of life have
improved. As shown on the pretransplantation and post-transplantation spirometry results, she had a
350% increase in spirometric volume; she also had a reduction in
Figure. Spirometry Before and After Lung Transplantation
dyspnea and a marked improvement
in quality of life.
DISCUSSION
Lung transplantation is a lifeextending extreme measure for
patients with the most severe cases
of COPD. It is unknown whether
this complex and risky procedure
could have been avoided or at least
delayed with earlier intervention in
this individual patient. Smoking
cessation is the 1 intervention
proven to alter the long-term
decline of lung function in smokers.
In conjunction with an aggressive
Advanced Studies in Medicine
■
S421
NOTES
S422
Vol. 3 (5B)
■
May 2003